THE GREAT DETTOL MAGIC by Jacob George

It stings. It pricks. And it has a pungent smell which reminds us of a hospital ward. But still people love Dettol. It has been a household name in India for about 78 years now, the most trusted antiseptic liquid of Indian mothers from generation to generation. The Dettol saga began in the year 1933. Even today, it is the default antiseptic liquid that people use for cuts and grazes, bites and stings and minor burns and scalds. This iconic brand continues its successful journey even today, with no potential threat coming up against it from any quarter. The brand has become synonymous with protection from germs. It’s identity is so strong that the whiff of Dettol in a room is enough to give one the assurance that this is a space that has no bacteria or germs in it.

Though Dettol was launched as a solution for fresh cuts and wounds, in India it was first used in hospitals and nursing homes for first aid and disinfectant uses like cleaning wards, washing hospital clothes etc. Very soon ordinary people started taking it as a first aid tool for their familes. Apart from being a liquid for cuts and wounds and even small burns, it was used for bathing, mopping and even shaving. Over the years, Dettol became the trusted brand of the people - not only in India, but in several countries across the globe.

     Today, Dettol is a formidable brand – one that has its iconic brand image standing tall. The unmistakable Dettol smell is very strong and clinical in nature, a kind of ‘hospital smell’. The painful fact is that it hurts when it is applied on fresh wounds. Mothers are happy when the child cries as Dettol is applied on the wound. Because she knows that the Dettol has started working. That it has started killing the germs and that the child is safe.  

     Dettol is a good multipurpose first aid liquid. Good to use for midwifery or to bathe with, to clean minor wounds and kill germs. When you use this for first aid, to clean grazes etc., you are reducing the risk of a cut or graze going septic. The sword on the logo of Dettol implies that the contents are intended to kill germs.

     Dettol has become an essential household product today. People use it for washing hands, in bath water and even as an after shave lotion. The brand is owned by Reckitt Benckiser India Ltd. (RBIL), a fully owned subsidiary of Reckitt Benckiser, a company that operates in 60 countries and sells its products in 180 countries. RBIL manufactures and markets a wide range of products in personal care, pest control, shoe care, antiseptics, surface care, fabric care etc. Apart from Dettol, the company also has other popular brands like Mortein, Harpic, Cherry Blossom, Lizol and Colin. All of these products have been successful in gaining a prime position in peoples’ perceptions through unique advertisements and excellent marketing techniques. For example, the Dettol brand has always focused on celebrating the mother’s role in protecting her family. 

     The antiseptic liquid market in India, estimated to be at Rs 150 crores, is dominated by Dettol which has about 85 % market share. Savlon, from Johnson & Johnson is the other significant player in the field with a market share of about 12%. The chemical name of Dettol is Para chloro meta xylenol (PCMX) and the main ingredient that defines its unique antiseptic property is an aromatic chemical-chloroxylenol. When poured into water, it produces a white emulsion which gives a cloudy look. This is because of the fact that some of the ingredients are insoluble in water.

     The steady growth of the Dettol brand over the years in India and several parts of the world is a big business lesson too. The only brand that has dared to challenge Dettol was Savlon. Despite a massive advertising campaign that was spread over a long time, Savlon could not overthrow the monopoly of Dettol.

     Though Dettol had a high penetration level and almost all households kept a bottle of it handy, they rarely used it. In order to stoke sales, Reckitt decided to expand Dettol’s usage beyond cuts and bruises. This resulted in a campaign that showed that Dettol could be used as an all-purpose antiseptic while shaving, rinsing babies’ nappies, as a general disinfectant and so on. At present, the brand has spawned yet product – namely, Dettol soap, which is a major contributor to the 230-crore turnover that the brand enjoys.

Dettol Vs Savlon the brand war

Here’s the story of how Savlon and Dettol came head-to-head in a fight to establish supremacy in the antiseptic kingdom. There have been studies that show that Savlon has a lot of advantages over Dettol. Test indications were that it is a more effective germ killer than Dettol. The reason for this is that Savlon is effective against both Gram Positive and Gram Negative germs.

Moreover, Savlon does not sting when applied on wounds as opposed to the sting that Dettol delivers. Savlon also scores higher on the scent front – the tests showed that Savlon’s scent was preferred to Dettol’s, which was felt to be more ‘clinical’.

After years of Dettol being King of Antiseptic Lotions, Savlon got a boost through this feedback and leapt into the arena, armed for a good fight. During its relaunch by Johnson&Johnson, the main areas focused on were Savlon’s better scent and its no-sting property. The product was positioned as an antiseptic that does not hurt while healing.

Dettol did not take the attack lying down. Their response was to target one of the most valuable Johnson & Johnson brands – Band-Aid. Dettol launched its own plasters. This was a blow for Savlon because the new Dettol plasters had the advantage of the existing brand value that Dettol had been enjoying for years.

Johnson & Johnson scrambled to protect Band-Aid by launching a series of variants in the medicated plaster segment. In doing so, resources were spent on defending Band-Aid rather than in advancing Savlon.

Savlon suffered heavily because it lost valuable support in terms of investment in brand building. Dettol had a brand equity built over more than five decades and it was not an easy task to break into that strong base.  However, Savlon was pushed to a back burner after Dettol introduced the plaster. And so it is that even today, Dettol rules the market.

jacobgeorgetvm@gmail.com 

Breast Cancer

Dr. JAYAPRAKASH MADHAVAN, Senior Oncologist in Kerala, and Head of KIMS Pinnacle Oncology, Thiruvananthapuram, gives an expert analysis to help empower you to combat breast cancer.

One of the biggest challenges that modern medicine faces today is understanding and dealing with the disease called cancer. The word “cancer” simply means uncontrolled growth of a few cells, which may invade into surrounding tissue and may even spread to other parts of one’s body. Breast cancer is the second leading cause of cancer deaths today, after lung cancer and is the most common cancer among women, excluding non-melanoma skin cancers.          

     Every woman is at a definitive risk of breast cancer, which is second only to cervical cancer among women in India. On rare occasions, men also present with breast cancer. The rise of breast cancer among women is being documented mainly in the metros, but it can be safely said that many cases in rural areas go unnoticed. It is reported that one in 22 women in India is likely to suffer from breast cancer during her lifetime. In Kerala, this is the most common cancer diagnosed among women. Statistics has it that approximately 4500-5000 women in Kerala develop breast cancer annually.       

     When diagnosed early, breast cancer can be treated using surgery, radiation therapy and systemic therapies (chemotherapy, hormones or both). If diagnosed in the early stages, this cancer is pretty much curable. Unfortunately, the majority of patients in India come in for treatment when the disease has already reached advanced stages. In such scenarios the onco-surgeon and oncologist have fewer options of treatment to offer to the patient and breast removal is a norm either with or without chemotherapy, followed by radiotherapy many times.  Since the incidence of breast cancer is increasing in India, it has become very important to prevent and detect it early in order to reduce breast cancer related fatalities.

Risk factors

Most breast cancers are sporadic, caused by multiple factors. Only about 5-10% are due to familial cancers. The hereditary breast cancer is traced to inherited mutation in the BRCA1 and BRCA2 genes. The main identifiable risk factors for breast cancer are family history of breast cancer, increasing age, early menstruation with late menopause, and women who have had no children or have had their first child after 30 years. There are also other factors like long-term use of post menopausal replacement therapy and early exposure of chest or breast to radiation.

Symptoms and early detection

                The most important feature of breast cancer is a lump that develops in the breast or surrounding area. The mass that develops is often painless. Since most breast cancers are painless, and not all lumps are cancers, it is advisable to follow the following steps to facilitate early detection. Women aged 40 and older should have a screening mammogram every year and should continue to do so for as long as they are in good health. Women in their 20’s and 30’s should have a clinical breast examination (CBE) as part of a periodic health examination by a health professional, at least every 3 years. After age 40, women should have a breast exam by a doctor or a trained nurse every year. 

Breast self exam (BSE) is another option for women starting in their 20’s. Women should be informed about the benefits and limitations of BSE. Any changes in the breast tissues to the doctor right away. Current recommendations emphasize that women at high risk (greater than 20% lifetime risk) should get an MRI and a mammogram every year. Women at moderately increased risk (15% to 20% lifetime risk) should talk with their doctors about the benefits and limitations of adding MRI screening to their yearly mammogram. Yearly MRI screening is not recommended for women whose lifetime risk of breast cancer is less than 15%.       

     Many a time breast cancer may present or be associated with skin changes called peau d’orange appearance (the skin will have a pitted surface, like the peel of an orange), dimpling of skin, nipple retraction, or crusting of the nipple. Associated nipple discharge may also be present. These are due to the strictures and contractions formed by the growing cancer beneath.

Diagnosis

      Diagnosis of breast cancer is done from history, physical examination and mammography. Diagnosis is confirmed by cytological or histopathological examination of a biopsy sample. Fine needle aspiration cytology (FNAC), core needle biopsy, incisional or excisional biopsies are done to obtain the tissue sample for examination. Pathological examination helps to grade the tumor, and assess the completeness of the surgery. Special immunohistochemistry examinations and molecular markers (like ER – Estrogen Receptor, PR– progesterone receptor or Her2Neu – Human Epidermal Growth Factor Receptor 2) help to assess the receptor status to predict the behavior of the tumor and select the appropriate treatment for a particular tumor. Medical science is moving to the era of personalized treatment.

Staging

     After confirming the diagnosis of breast cancer, staging investigations are done to assess whether the tumor has spread to other areas. Cancer can spread to lung, liver, bone and brain. So imaging studies like CT scan, MRI scan, bone scan and PET scan are done to rule out this possibility.   Once all the investigations are obtained, the patients are advised to decide the optimal management. Breast cancer patients require surgery, radiation, chemotherapy, hormones and biological agents for treatment.

Treatment

For treatment purposes breast cancer patients can be divided into three major groups  

     1- Early operable breast cancer 

     2- Locally advanced breast cancer

     3- Metastatic breast cancer

Surgery: Earlier the better

                Early breast cancer is operable and usually limited to breast alone or and to axillary lymph nodes. Treatment of early breast cancer has two components. The first step is local treatment surgery alone or surgery and radiation. The second step is systemic treatment - chemotherapy, hormones and biological agents. This systemic treatment is called adjuvant treatment.                        

Local treatment varies from removal of the breast and axillary lymph nodes (Modified Radical Mastectomy) to lumpectomy and radiation. (breast conservation treatment). In breast conservation treatment, the tumor with a thin rim of normal breast tissue all around the tumor is removed (lumpectomy). After lumpectomy, the breast is irradiated. Both mastectomy and breast conservation treatments have shown equal success in locally controlling and curing the tumor. In western countries 90% of patients present with early stage disease and the majority opt for breast conservation treatment. Even after a mastectomy, some high risk patients require post operative radiation to the chest wall and the armpit. Breast reconstruction surgeries can be done after the mastectomy.

Recurrence-Another threat 

     Adjuvant systemic treatment (supporting treatment) is given to early breast cancer patients because many such patients come back with the cancer recurring at distant sites. At present we do not have mechanisms to predict which patient is going to relapse and which patient is going to be cured by local treatment. Therefore, all are given adjuvant systemic treatment to prevent future recurrence of the disease. The choice of the drugs for adjuvant treatment is determined by factors like stage and grade of the tumor, age, menopausal status, and molecular markers

     Adjuvant treatment is given for a definite period of time. Almost all early breast cancer patients receive chemotherapy. Some of them require hormones and or biological agents like Trastuzumab in addition to chemotherapy. These adjuvant treatments are very effective in significantly reducing the number of breast cancer related deaths.

Locally advanced breast cancer

     More than fifty percent of women approach the doctor when the disease is at an advanced stage.  This group requires anterior chemotherapy to reduce the tumor  in order to facilitate complete surgery. After mastectomy they need local radiation to the chest wall and local lymphatic drainage area, along with systemic treatment.

Metastatic breast cancer

     When breast cancer spreads outside the breast and regional lymph nodes to distant areas, it is called Metastatic breast cancer. The objective of treatment at this stage, is control of disease and prolongation of life. Only subsets of patients achieve long term relief and cure. At present metastatic breast cancer is treated with systemic treatments. The main groups of drugs are chemotherapy, hormones and biological targeted drugs. These drugs are used in combinations or sequentially to control the disease and improve the quality of life. Occasionally patients need radiation treatment to bone and brain metastasis.

Prevention and early detection

     The incidence of breast cancer is increasing in India. It has been observed that lifestyle changes contribute much to this. Low fat intake and regular exercise can reduce the incidence of breast cancer. Drugs like raloxifene are effective in preventing breast cancer in the high risk group of women.

     Early detection is very important, because early stage breast cancer has a high cure rate. The currently available methods of early detection are self examination, Physician breast examination and Mammographic Breast Examination. Mammographic examination uses soft X-rays to image the breast. With this test we can detect tiny, even non palpable breast cancer. Mammography is used for women above 40 years. In high risk women below the age of 40, MRI examination of the breast is useful to detect early cancers. The American Cancer Society recommends annual mammographic examination for all women above 40 years of age.

     Early detection and adjuvant treatment of breast cancer have contributed immensely to reducing breast cancer related deaths. Early detection will help the majority of our women with breast cancer to undergo breast conservation treatment also, which in turn can help them lead a normal life.

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Women at high risk include those who:

•Have a known BRCA1 or BRCA2 gene mutation  •Have a first-degree relative (parent, brother, sister, or child) but have not had genetic testing themselves  •Have a lifetime risk of breast cancer of 20% to 25% or greater, according to risk assessment tools that are based mainly on family history

•Had radiation therapy to the chest between the ages of 10 and 30 years

•Have Li-Fraumeni syndrome, Cowden syndrome, or hereditary diffuse gastric cancer, or have first-degree relatives with one of these syndromes

Women at moderately increased risk include those who:

• Have a lifetime risk of breast cancer of 15% to 20%, according to risk assessment tools that are based mainly on family history (see below) 

• Have a personal history of breast cancer, ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS), atypical ductal hyperplasia (ADH), or atypical lobular hyperplasia (ALH) 

• Have extremely dense breasts or unevenly dense breasts when viewed by mammograms

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Loving the lepers

“I choose the poverty of our poor people. But I am grateful to receive the Nobel in the name of the hungry, the naked, the homeless, of the crippled, of the blind, of the lepers, of all those people who feel unwanted, unloved, uncared-for throughout society, people that have become a burden to the society and are shunned by everyone.” -Mother Teresa

In a world that was driven by schisms, skeptical of master plans and utopian schemes, this small woman refused to let ideology concern her, but instead shone as a beacon of humanity and compassion. She dedicated her life to the cause of humanity. Gentle, human and full of energy, Mother Teresa was an apostle of love devoted to the slums of Calcutta, who became a respected and beloved citizen of the world. Her selfless work among the poverty-stricken people of Calcutta is an inspiration for people all over the world.

     Mother Teresa’s primary work was among the lepers of Calcutta. India continues to have the largest number of leprosy patients, with 1.37 lakh new cases recorded every year. When Mother Teresa began her work, the social stigma attached to leprosy was strong. This was a major obstacle to self-reporting and early treatment. She took care of the lepers at a period when they were ostracized and often abandoned by their families.

     From childhood, Agnes Bojaxhio had a call to help the destitute. At the age of twelve, while attending a Roman Catholic elementary school, she records that she knew she had a vocation to help the poor. She decided to train for missionary work, and at the age of eighteen joined the Sisters of Loreto, an Irish community of nuns with a mission in Calcutta. After a few months of training in Dublin she was sent to India, where in 1928 she took her initial vows as a nun. On May 24, 1931, she took the name ‘Teresa’ in honor of St. Teresa of Avila, a sixteenth-century Spanish nun. From 1931 to 1948 Mother Teresa taught at St. Mary’s High School in Calcutta, but the suffering and poverty she glimpsed outside the convent walls left such a deep impression on her that in 1948 she requested and received permission from her superiors to leave the convent school and devote herself to working among the poorest of the poor in the slums of Calcutta.      

     In India’s slums, huge numbers of people were infected with leprosy, a disease that can lead to major disfiguration. Mother Teresa eventually created a Leprosy Fund and a Leprosy Day to help educate the public about the disease and established a number of mobile leper clinics. These started working in September 1957, and worked to provide lepers with medicine and bandages near their homes. By the mid-1960s, Mother Teresa had established a leper colony called Shanti Nagar (“The Place of Peace”) where lepers could live and work.      

     She persuaded the city of Calcutta that leprosy was not contagious and got the lepers to build a self-supporting colony at Titagarh that she named after Mahatma Gandhi.      

     Mother Teresa began an open air school for homeless children. She was later joined by voluntary helpers, and financial support was also forthcoming from various church organisations, as well as from the municipal authorities. On October 7, 1950, she received permission to start her own Order “The Missionaries of Charity”, whose primary task was to love and care for those persons that nobody was prepared to look after. Today the Order comprises about one thousand sisters and brothers in India, of whom a small number are non-Indian. Many have been trained as doctors, nurses and social workers, and are in a position to provide effective help for the slum population as well as to undertake relief work in connection with such natural catastrophes like floods, epidemics, famine and dealing with refugees. The Order provides food for the needy and operates hospitals, schools, orphanages, youth centers, and shelters for lepers and the dying poor. It now has branches in 50 Indian cities and 30 other countries.      

     While the hospitals were overflowing with patients who hardly had a chance to survive, Mother Teresa opened a home for the dying, called Nirmal Hriday (“Place of the Immaculate Heart”), on August 22, 1952. One of her happiest memories was of the man who said, as he lay dying in her lap, “All my life I have lived like an animal on the streets and now I am dying like an angel.” Her prize children, often without limbs or with terminal diseases, were ones she would rescue from dustbins. Each day, nuns would walk through the streets and bring people who were dying to Nirmal Hriday, located in a building donated by the city of Calcutta. The nuns would bathe and feed these people and then place them in a cot. These people were given the opportunity to die with dignity, with the rituals of their faith.

     From a single school which she started in a Calcutta slum in 1948, Mother Teresa’s Order grew into a multinational organisation that continued to be run from a small office in Calcutta. In the year before her death, her Order ran 755 homes in 125 countries. During that year the Missionaries of Charity fed half a million hungry mouths in five continents, treated a quarter of million sick, taught over 20,000 slum children and ran homes for the mentally destitute, the leprosy-afflicted, AIDS patients, the crippled, alcoholics and drug abusers. They ran day crèches, night shelters, soup kitchens and TB sanatoriums.

                Mother Teresa wore a sari similar to those worn by Calcutta’s municipal sweeper women, so that she could identify with the poorest of the poor. Later the saris worn by everyone in the Missionaries of Charity were woven by lepers’ hands. She believed in taking one small step at a time but had the administrative capability to perform many tasks simultaneously. Because she saw her God in everyone, she was able to bring out the best in their responses, big or small, which itself wrought a  chain of goodness that went around the world and made the work of the Missionaries of Charity possible.

Legacy and depictions of the Mother

Mother Teresa has been eternalized through the charity institutions she initiated. ‘Missionaries of Charity’, the international order established by Mother in 1950 consists of over 4,500 sisters and is active in 133 countries. Today, the Order consists of both Contemplative and Active Branches of Brothers and Sisters in several different countries who vow to give “Wholehearted and Free service to the poorest of the poor”.

Mother Teresa has been memorialized through Museums, been named patroness of various churches, and has had various structures and roads named after her, including Albania’s International Airport. In 2009, the Mother Teresa Memorial House was opened in her hometown Skopje, in the Republic of Macedonia.     

The Mother Teresa Women`s University-a public university, was established in 1984,in Kodaikanal, Tamil Nadu.

Various tributes have been published in Indian newspapers and magazines authored by her biographer, Navin Chawla.The Indian Railways introduced a new train, “Mother Express”, named after Mother Teresa, on 26 August 2010 to mark her birth centenary.

Mother Teresa is the subject of the 1969 documentary film and 1972 book ‘Something Beautiful for God’, a 1997 Art Film Festival award winning film starring Geraldine Chaplin called ‘Mother Teresa: In the Name of God’s Poor’ and a 2003 Italian miniseries titled Mother Teresa of Calcutta, (which received a CAMIE award). 

Yoga helps reduce radiation therapy side effects

Yoga offers unique benefits for breast cancer patients undergoing radiation therapy,says research from the MD Anderson Cancer Center, University of Texas. Patients who participated in the research performed yoga that incorporated yogic breathing, postures, meditation, and relaxation techniques into their treatment plan.They experienced improved physical functioning, better general health, and lower stress hormone levels.

     Lorenzo Cohen, PhD, professor and director of MD Anderson’s integrative medicine program led the study, which formally assessed the benefits seen in patients who performed yoga,compared to an active control group that performed only simple stretching exercises. The Swami Vivekanada Yoga Anusandhana Samsthana yoga Research Foundation in Bangalore, India, also collaborated in the study.

After completing radiation treatment, only the women in the yoga and stretching groups reported a reduction in fatigue. At one, three, and six months following the radiation therapy, women who practiced yoga during the treatment period reported greater benefits to physical functioning and general health. They were also seen to be more likely to perceive positive life changes from their cancer experience than women in the other groups. Women who practiced yoga also had the steepest decline in cortisol levels across the day, indicating that yoga had the ability to regulate this stress hormone.This is particularly important because higher stress hormone levels throughout the day, known as a blunted circadian cortisol rhythm, have been linked to worse outcomes in breast cancer,according to Cohen and colleagues.

Childhood Epilepsy: Make it stigma-free

Article by Dr.Arif Khan is a Senior Specialist Registrar in Pediatric Neurology at Leicester, London. He took his M.B.B.S. from Al Ameen Medical College, Karnataka and Diploma in Child Health from J.J.M Medical College, Karnataka. He is currently pursuing an MSc in Epilepsy from Leeds Metropolitan University, UK. He is a member of the General Medical Council, UK, Indian Medical Council, India, MDU Membership, British Medical Association, Royal College of Paediatrics and Child Health and the British Academy of Childhood Disability, UK. This is the first article in a series on Epilepsy in Children by Dr Arif Khan who will write articles on other areas of Pediatric Neurology as well.

Epilepsy is a condition in which disturbances to the brain’s normal electrical activity cause recurrent seizures or brief episodes of altered consciousness. Epilepsy comes in many forms and each person’s experience is different. The incidence of epilepsy in children is estimated to be 700 in every 100,000 children under 16 years. There are about 7 million children in Kerala below this age and therefore, about 7000 children with epilepsy. There is significant discrepancy in the care that these children receive, depending mainly on socio-economic status, geographical location and literacy.

     It’s not possible to prevent epilepsy from developing, but for those with the condition the chance of attacks can be reduced. Anti-epileptic medication can prevent seizures from recurring. Once epilepsy has been diagnosed and the doctor has discussed it with you, an anti-epileptic drug (AED) will be prescribed to prevent further seizures. The choice of drugs depends on your health and the type of epilepsy you have. The initial dose will be low and will be gradually increased until the seizures stop.       

     When a teenager or child of any age develops seizures, the impact on the family can be enormous. The effects of epilepsy on children’s behavioral, intellectual, and social development are extremely variable. Most children with epilepsy lead normal lives and have few or no restrictions on social or physical activities. Even if the seizures are well controlled, however, the diagnosis of epilepsy and the medical visits can be frightening to them. For some children, seizures and the effects of the antiepileptic drugs cause many difficulties. Other children have additional medical and neurological problems that affect their lives. Regardless of the severity of the condition, children with epilepsy need special attention to ensure that their outlook and self-esteem are positive.      

     Children with epilepsy see the disorder through the window of their parents’ eyes. On hearing the diagnosis of epilepsy, parents are likely to go through a series of responses: shock, bewilderment, disappointment, hopelessness, guilt, anger, and grief, but not necessarily in that order. The adjustment period is followed by the realization that life goes on, that the child and family can enjoy life and flourish. If the parents take a positive outlook, the child’s outlook will be positive.       

     The situation for children with epilepsy, in the developing world remains problematic. The misrepresentation of epilepsy often results in children with the condition being socially ostracized. Most children with epilepsy do not receive the treatment they require to bring their seizures under control and which would render their epilepsy less visible  to others.These children express a feeling of stigma and are more likely to report other impairments like low self-esteem, anxiety and depression which would additionally contribute to poor quality of life. They grow up into adulthood with reduced opportunities for social interaction, employment and marriage.       

                As responsible members of society, we ought to understand this stigma and work towards developing measures to overcome it. Both personal and public adaptation is required if the impact of stigma is to be lessened. Efforts to educate people with epilepsy and their families need to focus on the relation between knowledge, stigma and adjustment, and public education initiatives need to be further developed to promote increased awareness of epilepsy as both a social and medical disorder. Better awareness of the disease can very well reduce the misconceptions and misinformation about epilepsy that pose threats to the identity, self-esteem, security and opportunities of children with epilepsy.

Mammography

A mammogram is an x-ray of the breast. A diagnostic mammogram is used to diagnose breast disease in women who have symptoms or an abnormal result on a screening mammogram. Screening mammograms are used to look for breast disease in women who are asymptomatic; that is, they appear to have no breast problems. Screening mammograms usually take two views (x-ray pictures taken from different angles) of each breast. For some patients, such as women with breast implants, more pictures may be needed to include as much breast tissue as possible. Women who are breast-feeding can still get mammograms, but these are probably not quite as accurate because the breast tissue tends to be dense.Strict guidelines ensure that mammogram equipment is safe and uses the lowest dose of radiation possible. To put dose into perspective, if a woman with breast cancer is treated with radiation, she will receive around 5,000 rads, if she had yearly received 20 to 40 rads.

     For a mammogram, the breast is pressed between two plates to flatten and spread the tissue. This may be uncomfortable for a moment, but is necessary to produce a good, readable mammogram. The compression only lasts a few seconds. The entire procedure for a screening mammogram takes about 20 minutes. A black and white image of the breast tissue is obtained either on a large sheet of film or as a digital computer image that is read, or interpreted, by a radiologist (a doctor trained to interpret images from x-rays, ultrasound, MRI, and related tests).

                In females with very dense breasts or with cysts, ultrasound mammograms, nuclear mammograms called scintimammograms or MRI mammography may be advised. These are painless techniques and are reserved for specific cases and not used routinely.

Facing Diabetes

Article by Dr. Sreejith N. Kumar, Chairman of the Indian Diabetes Association and President of the Indian Medical Association, Thiruvananthapuram. Dr. Sreejith took his MBBS from Thiruvananthapuram Medical College and Masters in Medicine from Armed Forces Medical College, Pune. He also has a Diploma in Diabetology from Vuk Vrhovac Institute, Zagreb, World Health Organisation Collaborating center. He is the Editor of the Kerala Medical Journal and the Secretary of the Thiruvananthapuram Diabetes Club.

When your body is not making any insulin or isn’t making enough, your body can’t convert blood sugar- glucose- into fuel for your body’s cells. This condition is diabetes, an illness that is growing on a global scale. Find out the causes, symptoms and diagnosis of diabetes.

what is diabetes?

     Diabetes simply means an increased amount of glucose in blood. However the condition is not as simple as one might think, in terms of the disease per se and its causes.Most of the food we eat is turned into glucose, a form of sugar. We use glucose as a source of energy to provide power for our muscles and other tissues. Our bodies transport glucose in our blood. In order for our muscles and other tissues to absorb glucose from our blood, we need a hormone called insulin. Without insulin, our bodies cannot obtain the necessary energy from our food.

     Insulin is made in a large gland behind the stomach called the pancreas. It is released by cells called beta cells. When a person has diabetes, either their pancreas does not produce the insulin they need, or their body cannot use its own insulin effectively. Many new mechanisms leading to high blood glucose have recently been described. We will see some of the details later.

            People with diabetes cannot use enough of the glucose in the food they eat. This leads to the amount of glucose in the blood increasing. This high level of glucose or “high blood sugar” is called hyperglycaemia.All of us have glucose in our blood. Normally, it is <100 mg/dl before food and <140mg/dl after meal. In a diabetic patient this level increases to >126 mg/dl before and >200 mg/dl after food. The values in between Diabetes and normal ranges include impaired fasting glucose (IFG) and impaired glucose tolerance (IGT). These conditions are otherwise called pre-diabetes. Thus we have three sets of values as shown in the table below.

To see the full online flipper version of this article, click this link and search archives for the August 2011 issue. On clicking the thumb image of the cover you can read the whole magazine online.

There are many ways to check the blood glucose values. Usually we check the glucose level in the blood, drawn from a vein using a syringe or from the capillaries obtained by a finger prick. A fasting sample has to be taken after eight hours of overnight fasting. After meal blood is drawn two hours after breakfast. Ideally the post meal value should be obtained from a blood sample drawn two hours after consuming 75gm glucose dissolved in a glass of water.

                Diabetes is usually associated with some symptoms like Increased thirst, urination and unexplained weight loss.  If someone has these symptoms even one value of blood glucose more than 200 mg/dl will define diabetes. However, if someone does not have the classical symptoms of Diabetes, then a repeat check up done on a different day also has to be abnormal before the person can be labeled as Diabetic. Another method to diagnose Diabetes is by doing a test called HbA1C. Hb (Hemoglobin) is the pigment which gives red colour to blood. Some of the  Hemoglobin in the blood would combine with glucose. This is known as glycated Hemoglobin (Hb A1C). The glycated hemoglobin level can be estimated by some special techniques. The normal level is <5.4 %. If it’s more than 6.5%, the person is diabetic. Estimation of HbA1C has an advantage over blood glucose. The lifespan of the red blood cells is three months. Hence glycated hemoglobin gives an estimate of the blood glucose over the past three months. Blood glucose estimation can tell us the value only at that particular point of time. However HbA1C estimation has some limitations as well. In our country the standardization is not proper and all the A1C results we get may not be accurate. HbA1C estimation is difficult and also is eight to ten times more costly than blood sugar estimation and is therefore not yet very popular in India for diagnosis of Diabetes.
                If someone has  the symptoms of Diabetes he should check the blood glucose value to find out whether they are high. Even if there are no symptoms it is good to check blood glucose once in a while. We have some specific guidelines in this regard which will be detailed later. It is very important that Diabetes is detected and treated early. We have many new evidences coming up in this regard. So the message is clear – if in doubt check now, the earlier the better.


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Sick of Morning Sickness?

Pregnancy and nausea often go hand in hand.

Here’s your guide to the phenomenon of morning sickness.

Anyone who has had a baby will tell you that the glow of health that lights up a woman’s visage during early pregnancy is almost always accompanied by a ‘not- so-welcome companion’ – morning sickness. This is a feeling of nausea, which often leads to vomiting that occurs during the first few months of pregnancy.

     Some women have the odd bout of mild queasiness when they first wake up, while others may have to endure weeks or even months of feeling or being sick all day long. Morning sickness reportedly affects 80% of pregnant women. Since each woman is different and each pregnancy is unique, the severity of nausea and vomiting of pregnancy (NVP) will vary from woman to woman. Fortunately, this condition is generally mild and self-limited and can be controlled with conservative measures.

     No one knows exactly what causes nausea during pregnancy. Most researchers believe it is caused by a combination of the physical changes that take place in the mother’s body such as the elevated levels of hormones. There is also some research that indicates that the mother’s diet may also be a contributing factor – since  women who had a healthier, plant-based diet were found to have less or no morning sickness, whereas those with a high meat based diet were seen  to suffer more.

     Characteristically, nausea and vomiting begin around the sixth week of pregnancy. This is called ‘morning sickness’ because it occurs most often in the morning, but this does not in any way mean that the sickness is limited to the daytime. Many women experience NVP several times during the day and sometimes, at night. For 80% of expectant mothers, this condition wears off around the 12th week of pregnancy. The remaining 20% are usually afflicted by the condition for a longer period of time.

     Triggers for the NVP are usually smells and foods, with the most commonly reported aversions or repulsions being towards meat, fish, poultry and eggs. Interestingly, some doctors who research the condition, point out that these are the very foods that are most likely to carry harmful micro-organisms or parasites. This indicates that NVP could be the body’s own highly developed radar that encourages the mother to eat foods that are most beneficial to the baby during the most crucial days of fetal development.

How does it affect you?

     Most cases of nausea and vomiting in early pregnancy aren’t harmful to the mother or the unborn child. Rather, there are indications that the body could actually be expelling foods that were hard to digest, or were potentially damaging to the fetus when its developing internal organs are most vulnerable to parasites and chemicals. While short-term dietary deficiencies do not appear to have any harmful effects on the pregnancy’s outcome, severe and persistent nausea and vomiting pregnancy symptoms can affect the mother’s health.                                Most women experience nausea or have episodes of vomiting at certain points of the day, and can eat and manage to keep food down during the rest of the day. However, mothers who are acutely affected may be missing or skipping meals for days together, which could mean that the baby may not be getting all the necessary nutrients for optimal growth. Excessive vomiting in early pregnancy could lead to the loss of almost 5% or more of the mother’s body weight.

     About 1% of pregnant women worldwide suffer from excessive vomiting in pregnancy-medically called “hyperemesis gravidarum”. Hyperemesis Gravidarum (HG) is a severe form of morning sickness, with “unrelenting, excessive pregnancy-related nausea and/or vomiting that prevents adequate intake of food and fluids.” Hyperemesis is considered a rare complication of pregnancy but, because nausea and vomiting during pregnancy exist on a continuum, there is often not a good diagnosis between common morning sickness and hyperemesis.       

                One of the main things to watch out for during morning sickness is dehydration. This happens when the body does not have adequate amounts of fluids which may be caused by losing the fluids that were taken in, or by not consuming enough. Severe cases of dehydration may require intravenous fluids and vitamin supplementation from the hospital. Systematically rehydrate or seek medical attention if the mother shows signs of dehydration – such as infrequent urination or dark yellow urine.

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Tips to control nausea and vomiting

DIET – Food

• When you wake up, eat a few crackers, or similar carbohydrate –high substitute and then rest for 15 minutes before getting out of bed.    

• Eat small meals or snacks often so that your stomach does not become empty (optimally every 2 hours). Try not to skip meals.    

• Do not hesitate to eat whatever you feel like eating, whenever you want to.     

• If cooking odors trigger the condition, try to get soemone else to cook. If you have no other option, ventilate the room as well as you can.   

• Try eating cold food instead of hot (since cold food may not smell as strong as hot food).

DIET – Drinks

• Drink small amounts of fluids frequently during the day.    

• Avoid drinking fluids during meals and immediately before or after a meal.

LIFESTYLE

• Get plenty of rest since nausea tends to worsen when you are tired. Taking naps during the day is ideal since a pregnant woman needs more sleep in the first three months of pregnancy.    

•  You may need to take some time off work or make other arrangements for household chores and childcare.    

•  Do not hesitate to enlist the support of friends and family.     

•  Get plenty of fresh air and avoid warm places. Feeling hot can add to nausea.     

• Try ginger, an alternative remedy that is often effective in settling the stomach. Dosages of up to 250 mg four times a day appear to be safe.    

• Try taking your prenatal vitamins (one with a lower amount of iron if that mineral makes your nausea worse) with food or just before bed. If multivitamins make your nausea worse, take folic acid alone on a daily basis.

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